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Name
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Sex
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Address
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Phone
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E-mail
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Age
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Present
Complaint and duration:
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Past history
with details of treatment taken:
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Pulse:
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Blood Pressure
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Urine Habits
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Motion Habits
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Any other
tobacco/ alcohol etc
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Occupation
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Day/ Night
Routine Schedule
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Sleep Pattern
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Any special
family history
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Any allergy to
specific medicines:
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